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Presentation on theme: "COMPLEX NEEDS OF YOUNG DRUG USERS & OUR TREATMENT RESPONSE"— Presentation transcript:

National Drug Treatment Centre Board Conference Dublin, November 16/17th, 2006 Dr. Gerry McCarney

2 Complex needs of young drug users and our treatment response
A look at the needs of young people Drug use in adolescence Why treat now? Principles of development and delivery How we are responding to this need in an Irish context – service model Special needs / vulnerable groups

3 review of early clients
86 consecutive clients, 54/46 - female : male Adolescent age range 14-18, mean 16.8 yrs Drug history -Opiate users +/- other drug use 1st drug use age 12 , 14.7 Daily opiate use 12/12 Polydrug use 60%, inc. street methadone (78%) IVDA hx. 59% (33% currently), 64% not tested Study carried out by Dr.John Fagan et al- Fagan, Smyth & Naughton.

4 YPP- study findings cont’d
58% living with parents 30% homeless! (half in hostels) 9% partner 48% had been homeless 27% in care before 51% has SW input Left boys earlier 14% expelled, 50% dropped out 37% had work history

5 YPP- study findings 52% in relationship, 45% overall had a heroin using partner 45% hx. sibling opiate, 58% parental EtOH 48% convicted, 31% prison, 38% charges 52% saw psych., 11% admitted, 33% DSH BOYS earlier to leave school, use heroin, be in care,+ family hx. GIRLS-more likely to have relationship with user

6 What this says.. attendees at YPP exhibit a history of:
Early drug use progressing to daily use Have early care disruption/chaos + family history of substance misuse Use many drugs, many IVDA not tested Significant forensic involvement Significant co-morbidity Multi agency integration approach required

7 Maslow’s Hierarchy of Need
Help me , I cannot stop using! Every Child Matters 2004 – 5 outcomes mirror Maslow- being healthy, staying safe, enjoying & achieving, making a positive contribution, economic wellbeing. Norwood- coping information, rest left unattended. Then helping information, etc, enlightening, empowering , and so on.Level 1- breathe, eat, sleep. 2- safety, health, belongings. 3- friendship, sexual intimacy, communication. 4- self respect, respect from others, confidence, competence. The ‘need’ to use drugs can override all of the above

8 Needs of young drug misusers
Physical- shelter, food, clothes, Safety- from adults, peers, society, drugs Belonging- need for love-family attachment, communication, contact from others, non-judgemental care, Self-esteem- esteem, self concept, negative self view, anxiety, depression Autonomy- still dependent -on whom? Self actualisation- SUD can delay developmental process

9 Why people use drugs Reasons- curiosity, media, pos reinforcement, enhance sensations, increase psychophysical performance, social pressure, peer association & youth culture, After first try, other times may be a lot easier- pos reinforcemnet Drug use may be statistical ‘normal’ in some micro-communities ‘normalised’ in peer group-access & acceptable Cannabis ‘not a drug’ view- denial of risk Social acceptance of cocaine use increased Trans-generational SUD- heroin even! Adolescent factors- Bobby has covered

10 Why treat? ‘Normal for adolescents’?- rebellion, peer involvement, individuating, experimentation- BUT….adult addiction starts in adolescence. SUD has ‘epidemic character’ in adolescence Critical time – development, social & emotional learning, education & employment. Co-morbidity , psychosocial damage, criminality, trans-generational prevention. What can we prevent now- (Harrison 2001) – while ¼ remain clean, Rx does reduce overall use, symptoms, criminality, emotional distress

11 More reasons to treat! COST-EFFECTIVE- Godfrey UK study- for every £1 invested in Rx, save between £9-18. Looked at settings from Tier 1 to Tier 4. Keating- $7 return for every $1 spent. Crime- proposed link to 29% drop in crime in Dublin area due to increased MMT Hospital visits- alcohol, heroin, prescription drugs, injury, overdose- heroin related to more ‘all cause’ visits over time ( Tait 2002) Keating D, Hertzmann C, (1999) – developmental health and the wealth of Nations. Social, Biological and Educational Dynamics. New York- Guildford press. $7 return for every $1 spent- greatest return when spent in most deprived sectors of the population.

12 Treatment needs of young people

13 Response to treatment needs
medical /surgical Rx/ Medication Substitution Rx Needle exchange Viral Screening MULTI-AGENCY PARTNERSHIP WORKING biological Screening & education Functional analysis Counselling Brief MI CBT Family therapy Young Person Liaison with SW, probation, childcare, family, contraceptive advice psychological social Information

14 Service development Core aspiration- young people will use us! i.e., engagement & retention Current best practice, evidence based, accessible. Respect dignity, ethnicity, language, culture. Non-complex presentation of information . Information- how to get help, drugs, feelings, sexual matters, day activities, training, family. Policies & rules-client & staff safety, legal framework- police, probation, courts. Confidentiality- not absolute-child protection. Transitional care plan for before their eighteenth birthday.

15 Service delivery Listen to what young people tell us- try to develop services that they will engage with. Careful common assessment, information sharing, multi-agency working. Multi-system intervention Increase accessibility- self help programmes, drop in centres, OP access, day Rx centres. Information based intervention is suitable for Tier 1. Peer support and advice. Can be delivered in schools and youth groups also. Support & education for Tier 1 & 2 from Tier 3. Referral pathways clarified. NEED TO INVOLVE FAMILY IF POSSIBLE. Reform delivery & strengthen accountability-prevention & early intervention-drug misuse assessments to be part of all services- build service & workforce capacity. NTA Essential Elements document June 2005.

16 4 TIER MODEL Tier 1- No specialist skills in either adolescent MH or Addiction. Any professional working with young person. Tier 2- specialist skills in one of addiction or adolescent Tier 3- specialist skills in both areas. New developing service. Tier 4- specialist skills in both, and an inpatient / day hospital service. HAS integrated care pathways- common assessment framework & avoid duplication- information sharing, multi-agency partnership working. Will develop KPI’s and aim to prioritise high risk / vulnerable groups. Mainstream services should remain in contact and often be the co-ordinators.

17 4 TIER MODEL CAMH-child & adolescent mental health/ CAA- child & adol
4 TIER MODEL CAMH-child & adolescent mental health/ CAA- child & adol. addiction Tier level Specialist skills available to help young drug users Type of adolescent accessing service Type of intervention for drug use Intervention delivered by Examples of such services Intensity and duration NOT either CAMH or CAA Start of drug use Basic advice +/- referral Individual professional Teacher, SW, GP, A&E, PO Low intensity- ongoing Either CAMH or CAA Problems due to drug use Basic counselling, brief intervention, harm reduction Individual or MDT CAMHS, Addiction DTF, Medium intensity- Medium duration Both CAMH & CAA based in the community Substantial problems due to drug use Specialist counselling, family therapy, medication Specialist MDT in adolescent addiction Specialist adolescent addiction service Hi- intensity, Short / medium/ long term CAMH & CAA at In-Patient / Day hospital Severe problems or drug dependence Individual & family therapy medication, residential- detox / stabilise specialist MDT in adolescent addiction Specialist day hospital or in-patient adol. Addiction Very high intensity , Short/ medium/ long term Tier 1 Tier 2 Multi-agency working. Clear guidelines and role definitions. YOT, CAMHS, Looked after children- responsibilities remain, but greater wrap around care possible. Secondment a good learning opportunity. Tier 1-To ensure universal access, continuity of care. Identify those at risk. Tier2- reduce risks, reintegrate. Tier 3- deal with complex and multiple needs, reintegrate. Tier 4- for high intensity for high risk- medication, residential, MDT daily access. Tier 3 Tier 4

18 Tier 4 service thus far.. Tier 4 team – Project manager, key workers, nurses, counsellors, family therapist, SW, psychologist, doctors. Complementary- Artwork, Reiki, Music Token economy, card system, contingency mx, careplanning, case review, keyworker. Offer intensive day hospital /residential.

19 ROLE OF KEYWORKER ‘The link’ between young person & service
Co-ordinator / advocate / educator / identifier of resources / engager Frequent positive contact & support Monitor drug use & progress Facilitate engagement with family & team Limited outreach capacity Contact, connection, care.

20 Tier 3,2,1 service MDT Tier 3- two being developed in the community in Dublin. Multidisciplinary- core competency mix Local accessibility and integration Adaptable- offer brief early intervention Education and advice supportive role Multi-agency Tiers 1 & 2- some already in place, others in need of development.

21 YPP urinalysis results over past 3 years

22 Ready to stop?

23 How do we approach a session?
Each is still a young person, and deserves culturally appropriate respect as a person. Generally, the process is as for any other. Ensure the reason for and process of the assessment are explained. Drug issues need not be the first topic. If intoxicated, can ask advice of a colleague. If threatening, ask advice of colleague, and do not continue session. This is not common! Make the YP feel ‘it is about you & for you’. Capitalise on existing relationships, understanding the young person & continuing interpersonal relationships will strengthen care pathways. Holistic assessment. Joint assessment. Invite family, invite other agencies if appropriate, but make the YP feel that you listen to Him/Her !

24 Questions to ask re: drug use
Age at first use? Which drugs tried When started using on daily basis Method of taking – po, intranasal, IVDA Weekly /daily pattern Go thro’ each drug What it does for you? How much it costs How they pay for it Knowledge re: risks of drug use- effects of drugs, IVDA risk, sexual Forensic history Effect on friends & family Family history-context

25 Symptoms and ASUD Paranoid thoughts Delusions Hallucinations
Thought disorder Concentration Motivation Behaviour change Speech, affect Depression / Mania Anxiety Restlessness Appetite, energy Skin, nose, eyes Unexplained weight loss Self care, strange

26 Co-morbidity/ dual diagnosis
More violence, suicidal behaviour, service costs and poor Rx outcome in both populations. Increased threshold for entry to both services. 2003-UK. CMHT- 44% reported drug/harmful alcohol use. (adult) In addiction services- anxiety & depression both near 30%.Personality disorders common. Psychosis 10%. Poor coping, relationship problems, hopeless. DD-adolescent- 31% had psych.visit – 54% with prior Dx visited- girls & internalisers more likely -Sterling SF 2005 High rates of depression, anxiety, eating dis, ADHD, CD.

27 Early age alcohol consumption
Adolescent alcohol- 1% A/E admissions, 50% trauma admissions for that age group Underage drinking in unsupervised locations Aggression, violence, accidents and trauma Road traffic accidents- young men especially. DSH, depression, anxiety, PTSD , ADHD(CD). Alcohol problems are more predictive of suicidal behaviour in males.

28 Sexual risks Early menarche- more smoking & drinking
Disinhibition, reduced recall and self-awareness Sex for drugs, sex work STIs and early pregnancy Sexual / contraception knowledge Condom negotiation skills

29 Profile of Pregnant Drug User
Single & Poor Unemployed Unskilled Lack child care facilities Suffered trauma Poor parenting skills or confidence Increased stigma when pregnant Fear / suspicion of services Poor nutrition & dental care Infectious disease risk 50% have partner using

30 Treatment Aims (Day, 2003) Practical & emotional support offered
Ante- and post-natal use of multiple services- obstetric, medical, addiction, SS. Early booking appt. ensures safety & allows education re: care and benefits Promotion of child welfare Period of engagement is for duration of pregnancy and beyond, including advice re: family planning.

31 Forensic association Crime association- may share same risk factors only. predictive dose-response relationships in both directions. Violence, vandalism, fraud ~ adolescent drug use Theft not only assoc. with drug use. Peer behaviour & prior forensic hx also determine crime (Hammersley). Criminality reduces after residential Rx. High rate of SUD in prison population- all should be screened-Audit Commision UK & others Polydrug use ~90% boys . Studies- Howard 1990, Pottieger 1991, Hagell 1994, Misspent youth (audit commission 1996), Williamson 1996, Collinson ’94,’96- all found high drug use – most in the 90% reange, and mostly polydrug use. Boys more than girls, - crime & drug use studied by Hammersley in Scotland &

32 Drug offence prosecutions for U-17s by gender, 1995-2004.

33 Homeless – vicious cycle
Family breakdown & drug / alcohol use. SUD can exclude from a/c- many young Predictors- peer & family drug use & attitudes, psychological well-being Very difficult to engage- often hx of care Safety- violence, sexual violence, adult manipulation, criminality Treatment access after leaving prison

34 Early School- leaving Many leave school early- < 14.
Link in with delinquent peer group. 1/10 no qualifications, 1/5 no Leaving Cert. Effects of drug use- poor school performance, lose positive peer group and social skills enhancement. ESPAD figures. Comiskey & Miller 2000. Polydrug use.

35 Adolescent drug users - different from adults at presentation
Less dependence evident Binge pattern more common Intoxication effects prominent Often reluctant patients, hence ENGAGEMENT a big issue- this can be over months. Peer influence greater- family support vital. Rehabilitation- creative thinking required. Harm reduction is the overall aim- includes abstinence & stabilisation.

36 THANK YOU! Un Convention on the Rights of the Child Article 33 of UN CRC – ‘States parties shall take all appropriate measures, including legislative, administrative, social and educational measures, to protect children from the illicit use of narcotic drugs and psychotropic substances as defined in the relevant international treaties, and to prevent the use of children in the illicit production and trafficking of such substances.’


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